Charting in the Era of EMR, comment

In the original post, the author speaks about the previous method of recording patient information, i.e. the paper trail. Unfortunately, even in present time, many health care facilities still use paper charting. As a nurse outside a large metropolitan area, I have found that within the city, most facilities use electronic charting; outside the city, many of us are still required to use paper charting. In this legalistic medical climate, there is always another form, another checklist, another documentation – and unfortunately, in the busy aspects of patient care, it is possible to omit something that may become an important piece of documentation in the future. This became very real recently in my new job as a case manager in a large mental health facility. A large amount of documentation, dating back 3 years was required for survey in an individual with a seizure disorder, mental retardation and mental illness. Two cumbersome (and intimidating) paper charts were brought to me to study and locate the proper documentation – an original consent signed by the guardian giving permission for the individual to take seizure medications and antipsychotics, among other documents. After spending hours looking for necessary documentation, there were still missing pieces to the puzzle. Seizure disorder is usually diagnosed with the aid of an EEG, a product of technology which confirms bursts of neuron activity in the brain; nowhere was an EEG found. Recording of seizure activity was not only difficult to follow, but most likely incomplete since it was relying on human elements such as neat handwriting, remembering to chart and placing documentation in the proper place in the chart. Most antipsychotics and seizure medications have risk of potent adverse effects – sedation, anticholinergic properties, extrapyramidial effects, neuroendocrine changes and weight gain to name a few. Consent is required in the long term care facility. How much easier it would have been to look on a well produced electronic chart for this documentation – which never was located! Within this health care facility, nurses deal with the illness of the human mind on a daily basis. The amazing human mind also created electronic charting – information retrieval systems capable of tracking healthcare in an orderly, legible and easily accessible format. It makes sense to use informatics to improve patient care, nurse productivity and the retrieval of patient information.

Original Post
January 4, 2010
Title: Charting in the Era of EMR
I am still of the era of nurses that entered a patients room with my rounds sheet tucked into my uniform pocket. The secret was to not let the patient see this sheet, and be able to remember their name, main diagnosis, and what you needed to check in them. You would go through your complete assessment including vital signs, and when you left the room you would pull out your little sheet of paper and write down all of the information you just collected. This procedure was repeated for all eight of your patients. When you were done, you then sat at the nurses’ station and pulled the individual charts so you could transfer the information onto the required forms.

It is not hard to see how the electronic medical record has benefited the role of nursing. The first improvement is in time management. You can actually take the information and enter it once. This is the only time you write the information. The second advantage is in correct data entry. You can enter the data as you gather it. There is less chance of forgetting the information before you write it in the patient record. The third benefit is in gathering the correct information on each patient. Electronic medical records prompt you to gather the required information.

I speak purely from a hypothetical standpoint because I personally have not had the chance to utilize an electronic medical records system. Our hospital is still struggling to come up with the money required to purchase and implement a system. I can, however, dream about how easy it will make my life once we get one!!!